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Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
Insurer Invitation to Participate in New York Health Benefits Exchange
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Insurer Invitation to Participate in New York Health Benefits Exchange

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New York Benefits Exchange Invitation: http://www.zanebenefits.com/ …

New York Benefits Exchange Invitation: http://www.zanebenefits.com/

This Invitation was issued by the New York State Department of Health (DOH) to invite insurers that are licensed or certified in New York State to apply for certain health insurance plans to be qualified as eligible for certification as Qualified Health Plans (QHPs) to be offered through the New York Health Benefit Exchange (Exchange).

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  • 1. Invitation to Participate in the New York Health Benefit Exchange January 31, 2013NEW YORK STATE DEPARTMENT OF HEALTHOffice of the New York Health Benefit Exchange 1
  • 2. Schedule of Key EventsInvitation Released................................................................................January 31, 2013Letter of Interest Due............................................................................February 15, 2013Written Questions re: Invitation Due ...........................................................March 1, 2013Response to Written Questions re: Invitation ...........................................March 15, 2013Participation Form Submission Due Date.......................................................April 5, 2013Provider Network Submission Date..............................................................April 12, 2013Submission of Rates and Forms..................................................................April 15, 2013Anticipated Notification of Certification..........................................................July 15, 2013 2
  • 3. Table of ContentsSection I. Introduction and Overview A. Issuing Office and Purpose B. BackgroundSection II. Participation Requirements A. Licensure and Solvency B. Choice of Individual Exchange or SHOP Exchange C. Service Area D. Applicant-Specific Requirements 1. Health Insurer Applicant Product Offerings a. Essential Health Benefits b. Metal Levels c. Standard Products d. Child Only Offerings e. Catastrophic Plans f. Non-Standard Products g. Prescription Drug Coverage h. Dental Coverage i. Out- of- Network Offerings j. New Products k. Role of Brokers and Agents l. Navigators/In-Person Assistors 2. Stand-Alone Dental Applicants a. Essential Health Benefits b. Standard Products c. Non-Standard Products d. Other Applicable Provisions 3. Consumer Operated and Oriented Plans (CO-OPs) 4. Small Business Health Options (SHOP) Exchange a. Definition of a Small Group b. Employer Choice c. Minimum Participation Standards d. Payment and Grace Period 5. Health Savings Accounts & Health Reimbursement Accounts 6. Non-Discrimination E. Quality and Enrollee Satisfaction 1. Develop and Maintain a Quality Strategy 2. Quality Assurance Reporting Requirements 3. Consumer Assessment of Health Care Providers and Systems (CAHPS) 3
  • 4. 4. Quality Improvement Initiatives 5. Accreditation F. Network Adequacy 1. General Standards 2. Specific Standards Applicable to Health Insurer Applicants a. Network Composition b. Essential Community Provider c. Behavioral Health Providers 3. Specific Standards Applicable to Dental Benefits and Stand-Alone Carriers 4. Sanctioned Providers 5. Method of Review 6. Frequency of Review 7. Submission of Network G. Administrative Requirements 1. Enrollment and Member Services a. Enrollment Periods b. Enrollment Transactions c. Member Services General Functions d. Accessibility e. Treatment Cost-Calculators for Participating Providers f. Treatment Cost-Calculators for Out-of-Network Providers 2. Marketing Standards a. Exchange Marketing Outreach b. Applicant Responsibilities 3. Reporting a. General b. Timing and Instructions for Reporting c. Encounter Data d. Financial Reporting 4. Certification, Recertification and Decertification Process a. Certification b. Recertification c. Decertification d. Non-Renewal e. SuspensionSection III. Premium Rate and Policy Form Filing A. New York State Department of Financial Services (DFS) Statutory Authority B. Policy Form Filings C. Rate Filings 4
  • 5. Section IV. Federal and State Laws and Regulations A. Federal Laws, Regulation and Guidance B. State Laws and Regulations C. Medicaid and Child Health Plus ProgramsSection V. Application Process A. Issuing Agency B. Letter of Interest C. Inquiries D. Changes to the Application E. Submission of the Application F. Public InformationSection VI. Agreement with DOHATTACHMENTS Attachment A: Essential Health Benefits Attachment B: Standard Products Attachment C: Rating RegionsAPPLICATION RESPONSES Attachment D: Letter of Interest Attachment E: Participation Proposal Attachment F: Provider Network Submission Instructions 5
  • 6. Section I. Introduction and OverviewA. Issuing Office and PurposeThis Invitation is issued by the New York State Department of Health (DOH) to invite insurersthat are licensed or certified in New York State to apply for certain health insurance plans to bequalified as eligible for certification as Qualified Health Plans (QHPs) to be offered through theNew York Health Benefit Exchange (Exchange). Following the submission and review of theinformation required by this Invitation, the DOH will review whether Applicants and individualhealth plans meet all federal minimum participation standards and other requirementsnecessary for certification as a QHP. After Applicants and individual plans have been (i)reviewed and found to satisfy all minimum standards and requirements, and (ii) an Agreementis signed with the DOH, such health plans will be certified as QHPs available through theExchange. This will be the only opportunity for insurers to apply for certification to participatein calendar years 2014 and 2015, unless the DOH, in its sole discretion, determines that it is inthe best interest of consumers for the DOH to invite new applicants to participate in calendaryear 2015 to ensure adequate choice for consumers and small businesses, to provide continuityof coverage for consumers transitioning between Insurance Affordability Programs, and forother reasons determined by the DOH.B. BackgroundOn March 23 and 30, 2010, President Obama signed The Patient Protection and Affordable CareAct, Public Law 111-148 and the Health Care and Education Reconciliation Act, Public Law 111-152, respectively. The two laws are collectively referred to as The Patient Protection andAffordable Care Act (ACA). The ACA authorized the creation of state-based and administeredHealth Benefit Exchanges.On April 12, 2012, Governor Cuomo issued Executive Order No. 42 establishing the Exchangewithin the DOH. On December 14, 2012, the United States Department of Health and HumanServices (HHS) granted New York conditional approval to operate a state based Exchange.Starting on October 1, 2013, the Exchange will begin accepting applications for health insurancecoverage from individuals and small employer groups for coverage effective on January 1, 2014.The implementation of the Exchange will allow individuals and small businesses to shop andpurchase health insurance coverage through the Exchange; will allow individuals to receivefederal premium tax credits and cost sharing reduction benefits; enable small business toqualify for federal tax credits; and result in lower premiums for individuals and smallbusinesses. Based on simulation modeling conducted by the Urban Institute, over 1 millionpeople will enroll in health insurance coverage through the Exchange when it is fullyimplemented, including 615,000 individuals who purchase coverage directly and 450,000employees of small businesses who purchase coverage through the Exchange. Additionally, the 6
  • 7. value of the federal premium tax credits and cost sharing reduction benefits for individuals areestimated to be $2.4 billion per year and the federal tax credits for small business are valued atan estimated $200 million per year. For more information on the anticipated impact of theExchange, see the Urban Institute’s reports found on the Exchange information web site.New York’s Child Health Plus program will continue to cover eligible children in families withincomes up to 400% of the federal poverty level. Effective on January 1, 2014, New York intendsto expand Medicaid to cover adults up to 138% of the Federal Poverty Level.Section II. Participation RequirementsFor purposes of this Invitation, references to “Applicant” or “Applicants” shall mean all eligibleentities that, through this Invitation, may apply for QHP Certification, including health insurers,stand-alone dental carriers, and Consumer Operated and Oriented Plans (CO-OPs); referencesto “Health Insurer Applicants” means only health insurers applicants that offer medical benefitcoverage, including CO-OPs; and references to “Stand-Alone Dental Applicants” refers to onlydental carriers that are applying to offer stand-alone dental coverage. Unless expressly statedotherwise, all requirements set forth in this Invitation apply to all Applicants.A. Licensure and SolvencyPursuant to 45 CFR § 156.200(b)(4), Applicants must: • Be licensed as an insurer under Articles 42 or 43 of New York State Insurance Law or certified under Article 44 of New York State Public Health Law, in good standing, and in compliance with state solvency requirements at the time the application is submitted; or • Have applied for such licensure and reasonably anticipate being (1) licensed or certified prior to October 1, 2013 and (2) demonstrate to the satisfaction of the DOH that they have the capacity to be fully operational by October 1, 2013.B. Choice of Individual Exchange or SHOP ExchangeApplicants may apply to participate in both the Individual Exchange and Small Business HealthOptions Program (SHOP) Exchange, but are not required to participate in both.C. Service AreaApplicants must apply to participate in their entire service area as approved by the Departmentof Financial Services (DFS) or the DOH at the time of application. Applicants may apply to the 7
  • 8. DOH for an exception to this requirement by submitting a written request to the DOHexplaining the facts that justify the exception. The DOH reserves the right to grant exceptions tothis requirement on a case-by-case basis when it determines that granting such exception isnecessary, non-discriminatory and in the best interest of the Exchange. Pursuant to 45 CFR §155.1055, Applicants seeking participation must cover geographic areas that are establishedwithout regard to racial, ethnic, language, or health status-related factors, or other factors thatexclude specific high utilizing, high cost or medically-underserved populations.D. Applicant-Specific Requirements 1. Health Insurer Applicant Product Offerings a. Essential Health Benefits. Health Insurer Applicants must agree to provide the Essential Health Benefits specified by the DOH for calendar years 2014 and 2015, and delineated on Attachment A. The Essential Health Benefits must be included in the calculation of the actuarial values of the products. b. Metal Levels. Except for the impact of cost-sharing reduction subsidies, each product in each metal level must meet the following specified actuarial value (AV) levels based on the cost-sharing features of the product and determined using the HHS AV calculator found at http://www.cciio.cms.gov/resources/regulations/index.html#hie: Bronze : 60% AV Silver: 70% AV Gold: 80% AV Platinum: 90% AV A de minimus variation of +/- 2% AV is permissible. c. Standard Products. Health Insurer Applicants must offer one (1) standard product in each metal level and in every county of its service area. The standard product offered by Health Insurer Applicants must include the same benefits and visit limits as delineated in Attachment A and the same cost-sharing limitations delineated in Attachment B. This requirement applies to the Individual Exchange and the SHOP Exchange. d. Child Only offerings. In accordance with federal regulation, Health Insurer Applicants must agree to offer a child-only product at each metal level described in Section II.D.1.b., above, in the Individual Exchange. The child-only product must conform to the benefits and visit limits delineated in Attachment A and the same cost sharing limitations delineated in Attachment B. In other words, it must be the Standard Product required in Section II.D.1.c., above, offered at the child-only rate outlined in Section III.C.6.b. Only one child only product is required per metal level. Health Insurer 8
  • 9. Applicants’ participation in the State’s Child Health Plus program does not satisfy thisrequirement. e. Catastrophic Plans. Health Insurer Applicants must agree to offer at least onestandard catastrophic product in each county of the Applicant’s service area in theIndividual Exchange. The standard catastrophic plan can be found in Attachment B. Aspart of the Participation Proposal , which is attached as Attachment E, the DOH willrequire Health Insurer Applicant’s affirmative intent to offer a catastrophic product. Inthe event that the DOH determines there is adequate catastrophic coverage in aparticular county, the DOH may in its sole discretion allow other Health InsurerApplicants in the same county the option of not offering the Catastrophic Plan. The DOHwill inform the Health Insurer Applicant of this option during the certification processand the decision regarding inclusion/exclusion of the Catastrophic Plan will be made bythe DOH prior to certification. In the event there is not adequate coverage in aparticular county, all Health Insurer Applicants in that county will be obligated to offerthe Catastrophic Plan. f. Nonstandard Products. Health Insurer Applicants may opt to offer up to three(3) “non-standard” products at any metal level, and in all or any part of its service area.In proposing non-standard products, Health Insurer Applicants may either (i) substitutebenefits within certain categories listed below, (ii) modify cost-sharing in any category;(iii) add benefits to an essential health benefit category, including higher visitlimitations; and/or (iv) add benefits that are not considered essential health benefits,provided all changes are in accordance with federal and state regulation and guidance,as well as DFS review. The categories of benefits that may be substituted are: A. Preventive/Wellness/Chronic Disease Management B. Rehabilitative and Habilitative If affiliated entities of the Health Insurer Applicant apply to participate in theExchange, the limitation of three (3) non-standard products per metal level in eachExchange will apply to the Health Insurer Applicant and its affiliates collectively. Child-only products, catastrophic products and required out-of-network products will not becounted towards the three (3) non-standard product maximum. g. Prescription Drug Coverage. As required under the federal rules, prescriptiondrug coverage must cover at least the greater of (i) one drug in every United StatesPharmacopeia (USP) category and class; or (ii) the same number of prescription drugs ineach category and class of the benchmark plan chosen by the State. All prescription druginformation must be submitted to DFS for its review. This requirement is not intendedto limit the number of drugs that the Health Insurer Applicant may cover in a drugcategory or class. Health Insurer Applicants are encouraged to develop formularies that 9
  • 10. exceed the federal requirements when it is determined to be in the best interest of theirmembers. h. Dental Coverage. Federal law requires coverage for pediatric dental servicesand permits such services to be covered by health insurers or stand-alone dentalcarriers. Health Insurer Applicants must propose to offer pediatric dental benefits as aseparately priced benefit for each standard and non-standard product proposed for theExchange. In the event the DOH determines that there is adequate pediatric stand-alonecoverage available in a particular county by a stand-alone dental carrier, the HealthInsurer Applicant offering a QHP product in that county will have the option of includingthe pediatric dental benefit or deferring the offering to such stand-alone dental carrier.The DOH will inform the Health Insurer Applicant of this option during the certificationprocess and the decision regarding inclusion/exclusion of the pediatric dental benefitmust be made by the Health Insurer Applicant prior to receiving certification.Health Insurer Applicants will also have the option of offering adult dental, familydental, and/or supplemental pediatric dental benefits as an additional benefit perSection II.D.2.f., above. In the event the Health Insurer offers a family dental benefit, thepediatric component must include at least the same pediatric dental benefits asoutlined in Attachment A. i. Out-of-Network Offerings. To ensure that the consumers purchasing coveragehave the same array of choices in the Exchange that they will have outside theExchange, for 2014, a Health Insurer Applicant that offers an out-of-network productoutside the Exchange in a county, must also offer an out-of-network product throughthe Exchange in that same county. An “out-of-network” product is a product thatprovides coverage for services rendered by health care providers that are not in thehealth insurer’s network. Health Insurer Applicants required to offer an out-of-networkproduct must offer the out-of-network product on the Exchange at the silver andplatinum levels. This requirement applies to both the Individual Exchange and the SHOPExchange. j. New Products. All initial products offered through the QHP certificationprocess will have effective dates of January 1, 2014 in the Individual Exchange and SHOPExchange. Qualified Employers will be able to purchase coverage through SHOP at anypoint during the year, and may modify the effective date of coverage for any 12-monthperiod. Health Insurer Applicants, however, will not be able to establish and offer newproducts at any time during the year. Products to be offered during calendar year 2015,must be established and submitted to DOH and DFS through the 2014 recertificationprocess. k. Role of Brokers and Agents. To maximize access to health insurance coveragefor residents of New York State, brokers and agents (collectively, “Producers”) will bepermitted to assist both small businesses and individuals in purchasing coverage 10
  • 11. through the Exchange, provided that they have entered into an agreement with the Exchange. Such agreements will require Producers to be licensed and in good standing with the DFS. In addition, Producers seeking to assist small businesses and/or individuals will be required to complete an Exchange-approved training program and pass a test to certify completion of the program. Producers will be required to comply with all applicable provisions of federal and state law related to the provision of assistance to consumers, employers and employees in the Exchange and must have required privacy and security measures in place. All of Health Insurer Applicants’ compensation arrangements with Producers must be the same inside and outside of the Exchange, and must comply with all applicable provisions of State law. For example, the commission for a small group product offered on the SHOP Exchange must be the same as the commission for a small group product offered outside of the Exchange. In addition, for the sale of Exchange products, the Applicant must contract with Producers that have successfully completed the required training program and have entered into agreements with the Exchange. l. Navigators/In-Person Assistors. Consistent with the federal law, the DOH provides grants to qualified organizations to act as Navigators and In-Person Assistors for the Exchange. Navigators and In-Person Assistors will provide in-person, linguistically and culturally appropriate assistance to those applying for coverage through the Individual Exchange and/or SHOP Exchange. Health Insurer Applicants must cooperate with Navigators and In-Person Assistors that have contracts with the Exchange. 2. Stand-Alone Dental Applicants Stand-Alone Dental Applicants shall offer products through the Exchange in accordancewith federal and state laws and regulations, and in accordance with the following participationrequirements: a. Essential Health Benefits. The Stand-alone Dental Applicant must agree to provide the pediatric dental benefits outlined Attachment A. The pediatric dental benefits are minimum benefits and the Stand-alone Dental carrier may add benefits. b. Standard Product. The Stand-alone Dental Applicant must offer one standard pediatric stand-alone dental product in every county of its service area. The standard product offered by the Stand-alone Dental Applicant must include the same pediatric benefits as outlined in Attachment A. The Standard product can be offered at either a high level (85% AV) or a low level (75% AV), but not both. This requirement applies to both the Individual Exchange and the SHOP Exchange. 11
  • 12. c. Non-Standard products. The Stand-alone Dental Applicant may opt to offer up to two (2) non-standard products. The non-standard product may be adult dental, family dental or a second pediatric dental product offering. This requirement applies to both the Individual Exchange and the SHOP Exchange. d. Other Applicable Provisions. Stand-Alone Dental Applicants must meet the requirements set forth in Section II.D.1.k. and II.D.1.l., above. 3. Consumer Operated and Oriented Plans (CO-OPs) The DOH is partnering with the Center for Consumer Information and InsuranceOversight (CCIIO) with respect to participation of CO-OPs. Applicants designated as CO-OPsmust adhere to the standards and processes set forth in this Invitation. Once a CO-OP has metall the standards set forth in this Invitation, DOH will make a recommendation to CCIIO tocertify the CO-OP. CCIIO will determine whether to adhere to DOH’s recommendation andnotify the CO-OP and DOH of its decision. Once the CO-OP is certified, federal regulationsrequire it to be deemed certified for two (2) years, with recertification determined by CCIIO inpartnership with the DOH every two years. The CO-OP entity will be subject to the DOHdecertification criteria, however, and any recommendation of decertification will be made toCCIIO, which will make the final decertification decision and communicate this to the CO-OPand DOH. 4. Small Business Health Options Program (SHOP) Exchange In addition to the above participation requirements, Applicants seeking to participate inthe SHOP exchange agree to adhere to the following requirements: a. Definition of a Small Group. For calendar year 2014 and 2015, the definition of a small group shall mean a group of fifty (50) or fewer employees. b. Employer Choice. Through the SHOP Exchange, Qualified Employers will have flexibility of choice when determining the products to offer their employees, including the following options: • Selecting one metal level and all products within that metal level; • Selecting one specific health insurer and a specific product offered by such insurer; • Selecting one specific health insurer and offering multiple products from such insurer; • Selecting all metal levels and all health insurer products. 12
  • 13. The SHOP will also permit the ability to offer an “employee choice” model through defined contribution mechanisms. Qualified Employers will have similar options available to them for stand-alone dental products. c. Minimum Participation Standards. Consistent with State law and regulation, in order to enroll in non-HMO options offered through the Exchange, at least 50% of a Qualified Employer’s employees must have health insurance coverage. Employees that enroll in any product count towards meeting this participation requirement. If the employer still cannot meet the 50% participation requirement, the employer will be re- directed towards HMO options only. d. Payment and Grace Period. Applicants must adhere to the methodology and processes developed by SHOP for payment and remittance of premium. Applicant must provide employers purchasing health care coverage through the SHOP with a thirty (30) day payment grace period. 5. Health Savings Accounts and Health Reimbursement Accounts Health Savings Accounts (HSAs) and Health Reimbursement Accounts (HRAs) arefinancial mechanisms created under law and regulated by the Internal Revenue Service (IRS)that provide individuals with tax advantages to offset healthcare costs. HSAs are accounts heldby a trustee or custodian (i.e., a bank or health insurer) on behalf of individuals. HRAs areaccounts held solely by an employer on behalf of an employee. Both types of accounts requirethe individual/employee to be enrolled in a high-deductible health plan that meets IRS out-of-pocket limits. For more information, visit http://www.irs.gov/uac/Publication-969,-Health-Savings-Accounts-and-Other-Tax-Favored-Health-Plans.Applicants will be permitted to offer high deductible health plans that meet the IRSrequirements and may arrange for the applicable HSA and HRA, if requested by the consumerand/or employer. 6. Non-Discrimination Applicants must not, with respect to their QHPs, discriminate on the basis of race, color,national origin, disability, age, sex, gender identity or sexual orientation.E. Quality and Enrollee SatisfactionThe DOH monitoring of the quality of care delivered by entities whose products are certified asQHPs (Exchange Participants), will be ongoing and determined through use of a variety ofquality, utilization and satisfaction metrics that have been validated, have clinical relevance tothe populations served, and are widely in use by health plans serving other populations in NewYork State. Measuring performance across a wide range of quality metrics will assure Exchange 13
  • 14. members across the age spectrum and with various health conditions are included in thisassessment. This process will also help to establish the DOH’s active agenda for improvementand re-measurement. Public reporting of Exchange Participant performance will also be acentral feature of the DOH plan for quality oversight.Outlined below are the DOH expectations related to quality of care and enrollee satisfaction forwhich the Applicant must adhere: 1. Develop and Maintain a Quality Strategy Applicants must develop a quality strategy that encompasses all the requirements setforth in 1311(g) of the ACA. This strategy must be implemented, updated annually withprogress reported to the designated office of the DOH. The quality strategy should describehow the Applicant will address the following: A) improving health outcomes through the implementation of activities that shall include quality reporting, effective case management, care coordination, chronic disease management, medication and care compliance initiatives, including through the use of the medical home model, for treatment or services under the plan or coverage; (B) the implementation of activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional;PPACACON.005 HOLCPC (C) the implementation of activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; (D) the implementation of wellness and health promotion activities; (E) the implementation of activities to reduce health and health care disparities, including through the use of language services, community outreach, and cultural competency trainings; and (F) a description of any current or proposed innovative programs to expand access to mental health services including but not limited to telepsychiatry or consultative services for co-management of common behavioral health conditions in children and adults. 2. Quality Assurance Reporting Requirements All Applicants will be required to participate in the DOH Quality Assurance ReportingRequirements (QARR). The quality indicators in QARR are comprised of quality of care and 14
  • 15. utilization of service measures, largely adopted from the National Committee for QualityAssurance (NCQA) Health Care Effectiveness Data and Information Set (HEDIS) with New YorkState-specific measures added to address health issues of importance to the State. QARR datawill be used as a major component of Exchange Participant quality rankings that will appear onthe Exchange website and will also be used in identifying clinical best practices, as well as, areasof concern with respect to quality of care and administering the health plan benefit package.The QARR data collected from Exchange Participants will also be posted on the DOH website ineQARR and related publications.The QARR technical specifications are typically released during the fall season of themeasurement year, with reporting of QARR data due on or about the following June 15. Thecurrent QARR specifications for reporting year 2013 are posted on the DOH webpage and canbe viewed at the following link: http://www.health.ny.gov/health_care/managed_care/qarrfull/qarr_2013/docs/qarr_s pecifications_manual_2013.The Exchange Participants will be required to report quality measures as well as all otherrequired member-level files. QARR reporting will require all Exchange Participants to have: a) HEDIS Volume 2 b) Programming for all required measures (either in-house capability of through a vendor) c) An NCQA audit conducted by a licensed audit organization of their QARR data prior to submission to the DOH. d) A certified CAHPS vendor to administer CAHPSQARR submissions with respect to Exchange enrollment is anticipated to begin on or aroundJune 2015 for calendar year 2014. 3. Consumer Assessment of Health Care Providers and Systems (CAHPS) All Exchange Participants will also be required to annually survey a sample of theirExchange eligible members using the standardized CAHPS Health Plan Survey tool. The CAHPSHealth Plan Survey allows the DOH to assess many aspects of the members’ experience of care,including their access to care and services and their interactions with their providers and healthplan. The Exchange Participants may be required to add New York State-specific questions tothe tool to aid the state in learning about newly insured’s experience and/or to provideadditional demographic or clinical detail. Like QARR, the DOH uses CAHPS data to identify any 15
  • 16. opportunities for improvement and DOH analyses of CAHPS data may require some plans todevelop and implement quality improvement strategies.The initial CAHPs survey for Exchange Participants is anticipated to be scheduled on or aroundfall of 2014. 4. Quality Improvement Initiatives The DOH will require Exchange Participants to have the infrastructure in place (or theability to contract for such services) which allows them to implement their Quality Strategy andrelated improvement activities as well as participate in a variety of DOH sponsored qualityimprovement work. This could include administration of member’s surveys, offering membereducation/outreach or incentive programs, offering physician training and/or incentiveprograms, supporting systematic changes at the practice level and practice level assessmentsamong other things. The Exchange Participants will also be welcome to participate in DOHsponsored statewide improvement initiatives that target issues of importance such asreadmissions, coordinated care for members with chronic disease, and other topics.For Exchange Participants with performance that falls outside normal ranges for quality orsatisfaction performance, a barrier analysis and an improvement plan will need to be developedand operationalized once approved by the designated DOH office. 5. Accreditation For calendar years 2014 and 2015, the DOH will not require Applicants to be accreditedas a condition of participation. This requirement will be reviewed for calendar year 2016.F. Network AdequacyApplicants will establish and maintain a network of Participating Providers that is consistentwith 45 CFR § 156.230 and existing DOH managed care network adequacy standards.Specifically, Applicant must adhere to the following: 1. General Standards a) In establishing the network, the Applicant must consider the following: anticipatedenrollment, expected utilization of services by the population to be enrolled, the number andtypes of providers necessary to furnish the services covered in each product, the number ofproviders who are not accepting new patients, and the geographic location of the providers andenrollees. 16
  • 17. b) To be considered accessible, the network must contain a sufficient number and arrayof providers to meet the diverse needs of the enrollee population and to assure that all serviceswill be accessible without undue delay. This includes being geographically accessible (i.e.,meeting time/distance standards) and being accessible for people with disabilities. c) The DOH may, on a case-by-case basis, defer any of the contracting requirements setforth in this Section II.F if it determines there is sufficient access to services in a county. TheDOH reserves the right to rescind the deferment at any time should access to services in acounty change. 2. Specific Standards Applicable to Health Insurer Applicants a. Network Composition. The Health Insurer Applicant’s network must contain all of theprovider types necessary to furnish the Exchange products, including but not limited to:hospitals, physicians (primary care and specialists), mental health and substance abuseproviders, allied health professionals, ancillary providers, Durable Medical Equipment (DME)providers, home health providers, and pharmacies. Specifically, the Health Insurer Applicant’snetwork must meet the following: (i) Each county network must include a hospital; (ii) Each county network must include the core provider types and ratios established through the Provider Network Data System (PNDS); (iii) Provide a choice of three (3) primary care physicians (PCPs) in each county, but more may be required based on enrollment and geographic accessibility; (iv) Include at least two (2) of each required specialist provider types in each county, but more may be required based on enrollment and geographic accessibility; (v) meet the following time and distance standards: A. Primary Care Providers • Metropolitan Areas – 30 minutes by public transportation for primary care providers; • Non-Metropolitan Areas – 30 minutes or 30 miles by public transportation or by car for primary care providers; • In rural areas, transportation requirements may exceed these standards if justified. B. Other Providers • It is preferred, but not required, that the Health Insurer Applicant meet the 30 minute or 30 mile standard 17
  • 18. b. Essential Community Providers. Health Insurer Applicant is required to have asufficient number and geographic distribution of essential community providers, whereavailable, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in the Health Insurer Applicant’s service area. TheHealth Insurer Applicant must make every good faith effort to include in its network theessential community providers defined under federal regulation, and at a minimum, mustinclude in each county network a federally qualified health center and a tribal operated healthclinics, to the extent such providers are available. c. Behavioral Health Providers. The Health Insurer Applicant is required to includeindividual providers, outpatient facilities and inpatient facilities in its behavioral healthnetwork. The network must include facilities that provide inpatient and outpatient mentalhealth and inpatient and outpatient alcohol and substance abuse services. Facilities providinginpatient alcohol and substance abuse services must be capable of providing detoxification andrehabilitation services. 3. Specific Standards Applicable to Dental Benefits and Stand-Alone Dental Carriers The Applicant’s dental network shall include geographically accessible general dentistssufficient to offer each enrollee a choice of two (2) primary dentists in their service area and toachieve a ratio of at least one (1) primary care dentist for each 2,000 enrollees. Networks mustalso include at least one (1) pediatric dentist and at least one (1) oral surgeon. Orthognathicsurgery, temporal mandibular disorders (TMD) and oral/maxillofacial prosthodontics must beprovided through any qualified dentist, either in-network or by referral. Periodontists andendodontists must also be available by referral. The network must include dentists withexpertise serving special needs populations (e.g. HIV+ and developmentally disabled patients). 4. Sanctioned Providers The Applicant shall not include in its network any provider who a) has been sanctioned or prohibited from participation in Federal health care programsunder either Section 1128 or Section 1128A of the SSA; or b) has had his/her licensed suspended by the New York State Education Department orthe SDOH Office of Professional Medical Conduct. 5. Method of Review Network adequacy shall be reviewed by the DOH on a county-by-county basis. For somenetwork adequacy purposes, however, the county may be extended by approximately ten (10)miles beyond the county in the event the Applicant demonstrates a lack of health careresources or demonstrates that utilization patterns of consumers typically reside outside the 18
  • 19. county. In such cases, and for rural areas in particular, Applicants may contract with providersin adjacent counties to fulfill the network adequacy requirements. 6. Frequency of Review The DOH shall review the adequacy of an Applicant’s network upon submission of theapplication and on a quarterly basis thereafter. The frequency of submission and review will beincreased incrementally to monthly submissions. Until the frequency increases to a monthlysubmission, Applicants will make available to the DOH a URL link that provides an up-to-dateonline directory of providers. The DOH will make such link publicly available on the Exchangeweb site. 7. Submission of the Network The Applicant shall submit its network through the Health Commerce System (HCS) inaccordance with the Provider Network Submission Instructions set forth in Attachment F. TheDOH reserves the right to ask for further explanations and/or details in the event the system isnot able to capture or accurately identify particular service providers.G. Administrative Requirements 1. Enrollment and Member Services a. Enrollment Periods. The Applicant must adhere to the open enrollment periods established under 45 CFR § 155.410, 45 CFR § 155.725, and the special enrollment periods established under 45 CFR § 155.420. Enrollment is not effectuated until receipt of initial payment of premium from the prospective Enrollee. However, once payment is received, the Applicant must adhere to the grace period standards set forth in federal regulation for those Enrollees receiving Advance Premium Tax Credit assistance. For Enrollees in the Individual Market that do not receive Advance Premium Tax Credit assistance, once the initial premium is paid, the Applicant must provide a thirty (30) day grace period to pay premiums. b. Enrollment Transactions. In addition, the Applicant must be able to obtain HIPAA Compliant 834 and 999 transactions in accordance with the 834 and 999 companion guide developed by the DOH and CMS pursuant to law, regulation and guidance. c. Member Services General Functions. The Applicant must agree to operate a Member Services Department during regular business hours, which must be accessible to Exchange Enrollees via a toll-free telephone line. Personnel must also be available via a toll-free telephone line (which can be the member services toll-free line or separate toll-free lines) not less than during regular business hours to address complaints and 19
  • 20. utilization review inquiries. In addition, the Applicant must have a telephone systemcapable of accepting, recording or providing instruction in response to incoming callsregarding complaints and utilization review during other than normal business hoursand measures in place to ensure a response to those calls the next business day afterthe call was received. d. Accessibility. Information must be provided to prospective enrollees andenrollees in plain language and in a manner that is accessible and timely to individualswith disabilities, including accessible Web sites and the provision of auxiliary aids andservices at no cost to the individual in accordance with the Americans with DisabilitiesAct and section 504 of the Rehabilitation Act. In particular, the Applicant must: (i) Provide written materials in a prose that is understood by an eighth- grade reading level and must be printed in at least ten (10)-point type. (ii) Make available written materials and other informational materials in a language other than English whenever at least five (5%) of the applicants and/or enrollees of the Issuer in any county of the service area speak that particular language and do not speak English as a first language; or, alternatively, provide taglines in common non-English languages indicating the availability of written translation of materials in any language the prospective or current enrollee speaks. (iii) Make available verbal interpretation services in any language to current or potential enrollees who speak a language other than English as a primary language. Interpreter services must be offered in person where practical, but otherwise may be offered by telephone. (iv) Have in place appropriate alternative mechanisms for communicating effectively with persons with visual, hearing, speech, physical or developmental disabilities. These alternative mechanisms include Braille or audio tapes for the visually impaired, TTY access for those with certified speech or hearing disabilities, and use of American Sign Language and/or integrative technologies. To the extent HHS establishes standards on written materials and/or verbalmaterials for the Exchange that provides greater protections than the standards setforth above, Applicant shall adhere to such HHS standards. e. Treatment Cost-Calculators for Participating Providers. Prior to January 1,2014, the Applicant must have in place a treatment cost calculator available through anInternet Web site and such other means for individuals without access to the Internet.Such treatment cost calculators must be able to demonstrate enrollee cost sharingunder the individual’s plan or coverage with respect to the furnishing of a specific itemor service by a participating provider in a timely manner upon the request of theindividual. 20
  • 21. f. Treatment Cost-Calculators for Out-of-Network Providers. The Applicant willprovide the DOH with information on cost-sharing and payments with respect to anyout-of-network coverage pursuant to 45 CFR §156.220(a)(7). The Applicant will providea URL link to its out-of-network treatment cost calculator that will be made availableduring the open enrollment periods in the event the DOH does not maintain an out-of-network calculator on the Exchange web site.2. Marketing Standards a. Exchange Marketing and Outreach. The DOH is implementing a multi-facetedmarketing and outreach campaign focused on connecting New Yorkers with quality,affordable health insurance through its user-friendly website. The DOH will engage intargeted outreach to consumers through navigators, consumer advocates, smallbusinesses, brokers, Regional Advisory Committee members and other stakeholders topromote the use of the Exchange. The DOH will also initiate an advertising campaigndesigned to publicize the access to quality, affordable health insurance. b. Applicant Responsibilities 1. Applicant may conduct advertising campaigns, including television, radio,billboards, subway and bus posters. The Applicant may distribute marketing materials inlocal community centers, health fairs and other areas where potential enrollees arelikely to gather. 2. The Applicant shall use the logo and branding designated by the DOH inreferring to Exchange products in marketing and outreach activities including anyprinted materials. Such materials must prominently display the Exchange website andtoll-free telephone number. Applicant will cooperate in good faith with DOH’s marketingand outreach activities, including the development of advertising materials anddescriptive literature for its Exchange products. 3. Applicant may not employ marketing practices that will have the effect ofdiscouraging the enrollment of individuals or small businesses with significant healthneeds in their Exchange products. 4. The Applicant shall comply with all provisions of federal and State lawregulating advertising material and marketing practices. The Applicant’s advertisingmaterials must accurately reflect general information that would be applicable to anExchange Enrollee. Materials must not contain false or misleading information.Applicants may not offer incentives of any kind to potential enrollees to enroll in anExchange product or renew their coverage. 21
  • 22. 5. The Applicant is prohibited from door-to-door solicitations of potential enrollees or distribution of material, and may not engage in “cold calling” inquiries or solicitation. The Applicant may not require participating providers to distribute Applicant-prepared communications to their patients. Marketing may not take place in patient rooms or treatment areas. 6. Applicant will provide copies of advertising materials and/or descriptions of its advertising campaigns to the DOH upon request. 3. Reporting a. General. The Applicant will maintain a health information system that collects,analyzes and reports data. The system must be able to report on utilization, claims paymentpolicies and practices, periodic financial disclosures, enrollment and disenrollment information,claim denials, rating of provider practices, cost-sharing and payments with respect to out-of-network coverage, prescription drug distribution and cost reporting, quality and customersatisfaction reporting pursuant to the DOH reporting requirements, and any other informationrequested by the DOH and/or required under applicable federal and state laws or regulations. b. Timing and Instructions for Reporting. The Applicant must submit required reports tothe DOH in a manner consistent with federal requirements under Section 45 CFR Part 156, or asotherwise instructed by the DOH. c. Encounter Data. Exchange Participants will be required to submit encounter data forall contracted services obtained by each of their members. Encounters are records of eachface-to-face interaction a member has with the health care system and includes, outpatientvisits, inpatients admissions, dental care, emergency room and urgent care visits. Encountersfor ordered services such as pharmacy and labs shall also be submitted. An encounter iscomprised of the procedure(s) or service(s) rendered during the contact and includesinformation on site of service and may also include diagnosis information. An encounter shouldbe operationalized in an information system as each unique occurrence of recipient andprovider. Encounters are to be submitted on at least a monthly or more frequent basis throughthe DOH designated vendor in a format and manner to be prescribed by the DOH.For more information on current encounter data reporting requirements for plans servingMedicaid recipients, Applicants may visit the DOH website at the following address:http://www.health.ny.gov/health_care/managed_care/docs/dictionary_meds3.pdf d. Financial Reporting. Applicant shall submit financial reports, including certified annualfinancial statements, and make available documents relevant to its financial condition to theDOH and DFS in a timely manner as required by State and federal laws and regulations. 22
  • 23. Applicant must agree to also submit separate premium and expenditure reports, and anyadditional relevant financial reports and documents related to its financial condition, in amanner and form required by the DOH. 4. Certification, Recertification and Decertification Process a. Certification. The subject matter of this Invitation is strictly related to the initialapplication for participation. The Exchange will grant certification through SERFF and an emailnotification. All Applicants that meet the requirements set forth in this Invitation and enter intoan Agreement with the DOH, will have their health plans certified to be offered through theExchange. b. Recertification. Except with respect to Consumer Operated and Owned Plans (CO-OPs), notification of the opportunity for recertification will be provided to ExchangeParticipants no later than May 1st each year. Rates and forms must be filed in accordance withDFS processes and timelines. The Exchange will complete recertification on an annual basis onor before September 15 of each year. Further details of the recertification process will beestablished by the DOH and made available on its informational web site. c. Decertification. An Exchange Participant may be decertified if it fails to adhere to thecertification standards set forth in this application, fails to resolve state agency sanctions, failsto comply with any applicable corrective action plan, or fails to recertify. Decertification shalloccur in accordance with all applicable laws and regulations governing the removal of a productfrom the market, including notification to enrollees. In the event that the DOH determines thatan Exchange Participant must be decertified, the Exchange Participant will receive writtennotice of this determination and the opportunity for a hearing prior to decertification. Thehearing will be before the Commissioner of Health or his designee. Further details on thedecertification process and appeals process will be established by the DOH and made availableon its information web site. d. Non-renewal. Exchange Participants may opt not to renew participation in theExchange. The Exchange Participant must notify DOH of its decision to not renew in a mannerand timeframe that consistent with existing state law. The Exchange Participant must followapplicable laws and regulations in terminating the respective Exchange Participant from theExchange, including notification to enrollees. The DOH will monitor the transition process,coordinating processes with Exchange Customer Service and DFS to facilitate transition. e. Suspension. The DOH may suspend enrollment in a QHP in the event a respectivestate agency requires suspension, or in the event the DOH determines it is in the best interestof the public. Notification of such suspension shall occur in accordance with applicable laws andregulations. 23
  • 24. Section III. Premium Rate and Policy Form FilingA. New York State Department of Financial Services (DFS) Statutory AuthorityPursuant to sections 3201, 3231, 4235, and 4308 of New York State Insurance Law, the NewYork State Department of Financial Services (DFS) is authorized and directed to review andapprove policy forms and premium rates before such policy forms and premium rates may beissued or delivered. HHS has determined that New York State has an effective rate reviewmechanism and, as such, New York State is authorized to conduct rate review pursuant to Statestandards. Accordingly, pursuant to the requirements of the State Insurance Law, Applicantsmust file with DFS proposed policy forms and premium rates for Exchange products and obtainthe Superintendent’s approval of such policy forms and premium rates prior to delivering orentering into such contracts and prior to QHP Certification.B. Policy Form Filings 1. All policy forms for Exchange products submitted for 2014 offerings will beconsidered new products. 2. All policy form filings for Exchange products must be received by DFS by April 15,2013. 3. All policy forms for Exchange products shall be submitted to DFS for approval throughthe System for Electronic Rate and Form Filing (SERFF) in accordance with instructionsestablished by DFS and HHS. 4. DFS will develop a checklist and instructions for policy form filings, which will beavailable on the DFS website. Applicants should use the checklist and instructions to ensurethat all policy form submissions are complete. 5. DFS will develop model policy form language for Exchange products, which will beavailable on the DFS website All Applicants must use the model language.C. Rate Filings 1. All premium rates for Exchange products submitted for 2014 will be considered newproducts. 2. All premium rate applications for Exchange products must be received by DFS by April15, 2013. 24
  • 25. 3. All premium rate applications for Exchange products shall be submitted to DFSthrough SERFF in accordance with instructions established by DFS, DOH, and HHS. 4. DFS will develop a checklist and instructions for premium rate filings, which will beavailable on the DFS website. Applicants should use the checklist and instructions to ensurethat all rate application submissions are complete. 5. Applicants must use the federal AV calculator when determining whether theExchange products meet the actuarial values required for the respective products. To theextent the AV calculator is not built into the rate templates, Applicants must include in the rateapplication a printout from the AV calculator for each Exchange product submitted and a clearbenefit description for each product submitted. The federal AV calculator can be found athttp://www.cciio.cms.gov/resources/regulations/index.html#hie 6. Provisions Applicable to Health Insurer Applicants a. Rating Tiers. Individual and small groups products in New York are community rated in accordance with state laws, regulations and guidance, and Health Insurer Applicants cannot take into account age, sex, health status, occupation or tobacco use when establishing premium rates. All products shall be initially priced to reflect four tiers with the following relativities: Tier Relativities Single person 1.00 Singe + spouse 2.00 Single + child(ren) 1.70 Single + spouse + child(ren) 2.85 These relativities shall apply to 2014 rates in the Individual Exchange and SHOP Exchange. The Superintendent of DFS will review and may adjust the relativities for subsequent years. b. Child-only Products. In addition to the tiers specified above, Health Insurer Applicants must offer child-only products in conjunction with the standard product designs. Only one child-only product is required per metal level. Separate policy forms must be created and provided to enrollees of child-only products. The child-only rate must be set at 41.2% of the corresponding single rate product. The Superintendent of DFS will review this requirement and may adjust the factor for subsequent years. c. Risk Adjustment and Reinsurance. For 2014 and 2015, the Exchange has elected to utilize the federal risk adjustment methodology and reinsurance 25
  • 26. methodology. Health Insurer Applicant’s premium rates should reflect the anticipated impact of these programs. d. Single Risk Pool Inside and Outside the Exchange. Under the ACA and applicable regulations, Health Insurer Applicants must consider all of the enrollees in all non-grandfathered products offered by the Applicant to be members of a single risk pool in the Individual market and the small group market, respectively. This requirement applies to products offered both inside and outside of the Exchange for each market. Consequently, if the Health Insurer Applicant offers a small group or individual product on the Exchange, it should coordinate its rate application filings with the rate filings for non-grandfathered small group or individual products outside the Exchange. DFS will issue instructions as to how to coordinate the filings. Catastrophic plans will have their own risk pool. 7. Premium Rate Periods a. SHOP Products. Applicants may use quarterly rolling rates for Exchange productsoffered through SHOP, with a one year guarantee for the employer. For example, if theemployer’s plan year begins April 1, 2014, the rate provided to that employer will beguaranteed for all employees through March 31, 2015, as well as new employees or specialenrollments that occur during the plan year through March 31, 2015. b. Individual Exchange Products. Premium rates for Exchange products offered in theIndividual Exchange Market must run on a calendar year basis, from January 1 to December 31of the applicable year. 8. Rating Regions. When submitting products for rate review, Applicants must adhere tothe rating regions set forth on Attachment C.SECTION IV. Federal and State Laws and RegulationsA. Federal Laws, Regulation and GuidanceThe Applicant shall at all times strictly adhere to all applicable federal laws, regulations, andinstruction as they currently exist and may hereafter be amended or enacted, including thefollowing: • The Patient Protection and Affordable Care Act, Public Law 111-148 and the Health Care and Education Reconciliation Act, Public Law 111-152, respectively. The two laws are collectively referred to as the Affordable Care Act (ACA). 26
  • 27. ● 45 C.F.R. Parts 155 and 156 (2012) Exchange establishment standards and other related standards under the Affordable Care Act, insurance standards under the Affordable Care Act, including standards related to Exchanges. • Health Information Technology for Economic and Clinical Health Act of 2009 • Health Insurance Portability and Accountability Act of 1996 • The Privacy Act of 1974B. State Laws and RegulationsThe Applicant shall at all times strictly adhere to all applicable state laws, regulations, andinstruction as they currently exist and may hereafter be amended or enacted. Applicantacknowledges that such laws include, but are not limited to the following: a) Contracts/Insurance Companies and Non-Profit Medical and Dental Indemnity Corporations N.Y. Insurance Law § 3201, 11 N.Y.C.R.R. 52.1, et. seq. (Approval of policy forms) N.Y. Insurance Law § 3231 (Rating of individual and small group health insurance policies; approval of superintendent) N.Y. Insurance Law § 4235, 11 N.Y.C.R.R. 52.2 (Group Accident and Health Insurance) N.Y. Insurance Law § 4308 (Supervision of Superintendent) b) Access to Care ▪ N.Y. Public Health Law § 4403(5)(a), 10 N.Y.C.R.R. 98-1.13(b) (Health Maintenance Organizations, network adequacy) ▪ N.Y. Public Health Law § 4403(6)(a), 10 N.Y.C.R.R. 98-1.13(a) (Health Maintenance Organizations, access to appropriate providers) ▪ N.Y. Public Health Law § 4403(2), 10 N.Y.C.R.R. 98-1.13(j) (Health Maintenance Organizations, emergency health services) ▪ N.Y. Public Health Law § 4403(2), 10 N.Y.C.R.R. 98-1.6, 10 N.Y.C.R.R. 98-1.12 (Health Maintenance Organizations, quality management program) ▪ N.Y. Insurance Law § 4325 (Prohibitions) ▪ N.Y. Insurance Law § 3224-a (Standards for prompt, fair and equitable settlement of claims for health care and payments of health care services) 27
  • 28. c) Access to Information ▪ N.Y. Public Health Law § 4403(2), 10 N.Y.C.R.R. 98-1.16 (Disclosure and filing) ▪ N.Y. Public Health Law § 4405-b (Duty to report) ▪ N.Y. Public Health Law § 4408 (Disclosure of information) ▪ N.Y. Public Health Law § 4910 (Right to external appeal) ▪ N.Y. Insurance Law § 4323 (Marketing material) ▪ N.Y. Insurance Law §§ 3217-a and 4324 (Disclosure of information)C. Medicaid and Child Health Plus ProgramsApplicants that also participate in the Medicaid Managed Care Program and the Child HealthPlus Program shall adhere to the requirements of the respective programs. Nothing containedherein shall be interpreted to supersede the laws, regulations, guidance or instructions issuedunder the Medicaid Managed Care Program and Child Health Plus Program.Section V. Application ProcessA. Issuing AgencyAs stated in Section I.A., this Invitation is issued by the DOH. DOH is responsible for therequirements specified herein and for processing all Applications in partnership with the DFS.This Invitation has been posted on the DOH Exchange informational website.DOH shall review Applications in an objective, comprehensive manner designed to benefit boththe Exchange and Applicants. The DOH intends that all Applications will be reviewed uniformlyand consistently. For the purpose of its review, the DOH may seek assistance from any person,other than one associated with an Applicant.B. Letter of InterestProspective Applicants are requested to submit a non-binding Letter of Interest as soon aspossible but no later than the date set forth in the Schedule of Key Events timetable containedon page 2 of this Invitation, via electronic or regular mail at the addresses set forth in paragraph 28
  • 29. C below. Submission of the Letter of Interest does not bind a prospective Applicant to submitan Application. If a prospective Applicant would like to receive e-mail notification ofupdates/modifications to the Invitation, including the issuance of DOH responses to questionsraised regarding the Invitation, the prospective Applicant may include such request in theirLetter of Interest. A Form Letter of Interest is attached to this Invitation as Attachment D.C. InquiriesAll responses and requests for information concerning this Invitation by a prospective Applicantor an Applicant, or a representative or agent of a prospective Applicant or Applicant, should bedirected to the contact listed below. In order for DOH to address questions efficiently,prospective Applicants are requested to send their inquiry in writing by email to the emailaddress below. Inquiries of a technical nature may result in either a written response or areferral to the appropriate individual for a verbal response (e.g., guidance and assistanceregarding use of the HCS System). To the extent possible, written questions concerning aspecific requirement of the Invitation should cite the relevant section of the Invitation for whichclarification is sought. Questions of this nature will be responded to by the DOH in writing andsuch questions and answers will be posted on the website in Section V.A., above, unless theparty submitting a question maintains that the question/answer will contain confidentialand/or proprietary information.CONTACTNAME: Invitation AdministratorEMAIL: nyhxpm@health.state.ny.usADDRESS: New York Health Benefit Exchange NYS Department of Health Corning Tower, Suite 2378 Albany, New York 12237D. Changes to the ApplicationThe DOH reserves the right to: 1. Withdraw the Invitation at any time, at the DOH’s sole discretion. 2. Disqualify any Applicant whose conduct and/or Application fails to conform tothe requirements of this Invitation. 3. Seek clarifications and revisions of Applications. The DOH may requireclarification from individual Applicants to assure a complete understanding of the Applicationand/or to assess the Applicant’s compliance with the requirements in this Invitation. 29
  • 30. 4. At any time during the Invitation process, amend the Invitation to correct errorsor oversights, and to supply additional information. Prospective Applicants are advised that atany time during the course of this application process, pertinent federal and state laws,regulations, and rules may change, and the protocol for using required systems such as SERFFand HCS may change. In addition, scheduled dates may need to be adjusted. All ProspectiveApplicants and Applicants will be informed of such changes, and Applicants may be directed tosupply additional information in response to such amendments.E. Submission of the Application 1. Application. As part of the certification process, Applicants are required to submit thefollowing, which collectively constitutes the Application: a. Participation Proposal b. Submission of Policy Form and Rates c. Submission of Provider Network InformationEach of the three component parts must be received by the due dates set forth in the Scheduleof Key Events listed in this Invitation. Late submissions may not be accepted. 2. Instructions: a. Participation Proposals. Applicants shall submit two (2) original, signed copies of theParticipation Proposal by mail or hand delivery to the address listed above in Section V.C.Electronic submissions are also required and can be sent to the email address noted in SectionV.C. Participation Proposals will not be accepted by fax. The Participation Proposal must besigned and executed by an individual with capacity and legal authority to bind the Applicant tothe authenticity of the information provided. The Participation Proposal Form to be completedand submitted by Applicants is attached to this Invitation as Attachment E. b. Submission of Policy Form and Rates. As set forth in Section III, Exchange products,rates and policy forms must be submitted to DFS per DFS instruction, which will be available onthe DFS website. c. Submission of Provider Network Information. As set forth in Section II.F.7, Applicantsshall submit their network through the Health Commerce System (HCS) in accordance with theProvider Network Submission Instructions contained in Attachment F to this Invitation. d. Vendor Responsibility. On or around the same time Applicants submit Forms andRates, Applicants will be notified of their responsibility to complete the New York State “vendorresponsibility” process through the New York State VendRep System. The VendRep SystemInstructions are available at www.osc.state.ny.us/vendrep or go directly to the VendRep system 30
  • 31. online at https://portal.osc.state.ny.us. For direct VendRep System user assistance, the OSCHelp Desk may be reached at 866-370-4672 or 518-408-4672 or by email athelpdesk@osc.state.ny.us.F. Public InformationDisclosure of information related to this Invitation process and resulting contracts shall bepermitted consistent with the laws of the State of New York and specifically the Freedom ofInformation Law (FOIL) contained in Article 6 of the Public Officers Law. Informationconstituting trade secrets or information that if disclosed would cause substantial injury to thecompetitive position of the subject enterprise for purposes of FOIL shall be clearly marked andidentified as such by the Applicant upon submission. Determinations regarding disclosure willbe made when a request for such information is received by the DOH Records Access Office.VI. Agreement with DOHFollowing completion of the activities outlined in this Invitation and having been determined tohave met all the requirements, the DOH will offer Applicants with the opportunity to enter intoan Agreement. The Agreement resulting from this Invitation will be effective only uponapproval of the New York State Office of the Attorney General (OAG) and the Comptroller ofthe State of New York (OSC). Applicants must enter into an Agreement with the DOH in orderfor their products to be certified as QHPs and to offer such QHPs through the Exchange.It is expected that the Agreement will be for the period commencing on or around August 1,2013 and extending for a twenty year period, subject to the approvals of the OAG and OSC. 31

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